KING'S COLLEGE LONDON

Research Conference 2014 Florence Nightingale School of Nursing and

Midwifery

Research Poster Presentations

2

Loujain Sharif .......................................................................................................................................... 6

The development and evaluation of educational interventions with differential hypothesised mechanisms of action to reduce mental illness related stigma amongst undergraduate Saudi Nursing students ................................................................................................................................. 6

Mary Sheridan ......................................................................................................................................... 7

Use of case studies to identify strategies to support evidence based management of term breech pregnancies: Phase 2 of the ‘Think Breech’ UK study. ........................................................................ 7

Petra Stolz Baskett .................................................................................................................................. 8

Needs assessment in caregivers of older cancer patients using the German version of the Supportive Care Needs Survey for Partners and Caregivers (SCNS-P&C44) ....................................... 8

Petra Stolz Baskett .................................................................................................................................. 9

Qualitative exploration of experience and needs of informal care givers of gerontology-oncology patients undergoing ambulatory chemotherapy. ............................................................................... 9

Suzanne Bench ...................................................................................................................................... 10

The feasibility and effectiveness of user centred critical care discharge information to enhance critical illness recovery ...................................................................................................................... 10

Yu Chen ................................................................................................................................................. 11

Validity and reliability of the modified Chinese version of the Older People's Quality of Life Questionnaire (OPQOL) in older people living alone in China .......................................................... 11

Yu Chen ................................................................................................................................................. 12

An exploratory study of quality of life of older people living alone on mainland china ................... 12

Jason Gray ............................................................................................................................................. 13

Activities and Interventions of nurses in A & E Departments. ......................................................... 13

Rosamund Snow ................................................................................................................................... 14

The role of patient expertise inside and outside the health system: patient education in diabetes .......................................................................................................................................................... 14

Wladzia Czuber Dochan ........................................................................................................................ 15

Researching patients’ experience: challenges of analysing qualitative phenomenological data using Moustakas’ method and NVivo software ......................................................................................... 15

Heather Jarman ..................................................................................................................................... 16

A qualitative study of emergency nurses’ experiences of working in a reconfigured major trauma system ............................................................................................................................................... 16

Maggie Tarling....................................................................................................................................... 17

The characteristics of safety climate in different acute adult nursing practice settings: Preliminary results ................................................................................................................................................ 17

Louise Barriball ...................................................................................................................................... 18

3

Evaluation of a Fast Track Health Visitor Initiative: The views of students, managers and practice teachers ............................................................................................................................................ 18

Mamdouh El-hneiti ............................................................................................................................... 19

An exploratory study of the nurse’s role in health promotion and cardiovascular disease in Jordan .......................................................................................................................................................... 19

Rebecca Blackwell ................................................................................................................................. 20

Geriatric-Only Emergency Room in New York: Fieldwork Informing an Experience-Based Co-Design study of palliative care for older people in the Emergency Department in the UK through a Florence Nightingale Foundation travel scholarship ........................................................................ 20

Wei Zhang ............................................................................................................................................. 21

Nurses' attitudes toward the information and communication technology in the healthcare delivery system: A systematic review ............................................................................................... 21

Lallita Carballo ....................................................................................................................................... 22

Multidisciplinary clinical decision making in colorectal cancer teams: A mixed method, multi stage investigation into the contribution of the clinical nurse specialist within the multidisciplinary team meeting. ............................................................................................................................................ 22

Asmah Husaini....................................................................................................................................... 23

A metasynthesis of the roles of nurses in providing end of life care for cancer patients ................ 23

Virginia La Rosa Salas ............................................................................................................................ 24

Combining motivational and volitional interventions to promote healthy behaviours: a web based RCT .................................................................................................................................................... 24

Sarah Jane Besser .................................................................................................................................. 25

Developing and testing a psychological intervention to promote adherence to osteoporosis treatment: a case series approach.................................................................................................... 25

Kathy Swanzy-Asante ............................................................................................................................ 26

Challenges of recruiting to a study about compassionate care in acute mental health care setting .......................................................................................................................................................... 26

Angela Parry .......................................................................................................................................... 27

An exploration of the literature on Registered Nurse medication administration error ................. 27

Veronica Zuccolo ................................................................................................................................... 28

Women’s decisions and experiences about infant feeding - a longitudinal qualitative study ......... 28

Simon Walne ......................................................................................................................................... 29

How nurses manage interruptions in dynamic environments ......................................................... 29

Jacqueline Sin ........................................................................................................................................ 30

Credibility vs anonymity: Views of siblings of young people with psychosis on a web-based educational and peer support intervention...................................................................................... 30

Laura Nasir ............................................................................................................................................ 31

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Enabling multidisciplinary teams to span organizational and sectoral boundaries for the improvement of patient care ............................................................................................................ 31

Ranjita Dhital ......................................................................................................................................... 32

Barriers and enablers experienced by pharmacists to delivering alcohol brief intervention. ......... 32

Helen Jones ........................................................................................................................................... 33

The organisational structure of the UK research nurse workforce in university NHS Trusts ........... 33

Ben Hunter ............................................................................................................................................ 34

Delivering health services through the private sector: experiences from a maternal health programme for low-income groups in northern India...................................................................... 34

Aniek Woodward .................................................................................................................................. 35

Medical training, professional trajectories, and the social contract in ‘post-conflict’ Sierra Leone 35

Kathryn Dennick .................................................................................................................................... 36

Written emotional disclosure (WED) for adults with Type 2 diabetes: feasibility and preliminary effectiveness ..................................................................................................................................... 36

Samantha Shaw ..................................................................................................................................... 37

Developing and evaluating a brief online educational intervention for fostering nursing students’ compassion. ....................................................................................................................................... 37

Maeve O’Connell ................................................................................................................................... 38

Midwives experience of using the carbon monoxide breath test for smoking cessation in pregnancy.......................................................................................................................................... 38

Lesley Dibley ......................................................................................................................................... 39

Coming out about Inflammatory Bowel Disease (IBD): transferable skills from the gay, lesbian, bisexual and transgender (GLBT) population in the UK .................................................................... 39

Lesley Dibley ......................................................................................................................................... 40

Help-seeking for faecal incontinence in people with inflammatory bowel disease (IBD) ................ 40

Kirstie Coxon ......................................................................................................................................... 41

Do birth place decisions change over a woman’s childbearing career? ........................................... 41

Nicola Mackintosh................................................................................................................................. 42

The Hidden Nature Of ‘Diagnostic Rescue’ Work ............................................................................. 42

Tracy Lindsay ......................................................................................................................................... 43

Critical Reflections on Interpretative Phonological Analysis (IPA) .................................................... 43

Geraldine Lee ........................................................................................................................................ 44

A pilot study to determine the feasibility of a pre-operative intervention in patients with diabetes undergoing cardiac surgery .............................................................................................................. 44

Julia Philippou ....................................................................................................................................... 45

Don’t forget to get pregnant! The synchronism and asynchronism of family and career. .............. 45

5

Lynn Sayer ............................................................................................................................................. 46

Pennies from Heaven: Using Opportunistic Funding for Workforce Development and Evaluation Research ............................................................................................................................................ 46

Katerina Iliopoulou ................................................................................................................................ 47

Impact of an educational multimodal program on rate of ventilator-associated pneumonia in an intensive care unit in one Greek Hospital ......................................................................................... 47

Henrietta Mulnier ................................................................................................................................. 48

The effect of a self-management programme on glycaemic control and weight in people with established diabetes in Lambeth and Southwark. ............................................................................ 48

Lesley Bridges ........................................................................................................................................ 49

The Impact of Postgraduate Advanced Practice Programmes; An Evaluation Study ....................... 49

Tanya Graham ....................................................................................................................................... 50

How are topical opioids used to manage painful cutaneous lesions in palliative care? A critical review................................................................................................................................................ 50

Vania Gerova ......................................................................................................................................... 51

Emergency Caesarian section of low and high risk women: the impact of maternity staffing, NHS England 2010/11 ............................................................................................................................... 51

Uta Grosse ............................................................................................................................................. 52

The Experience of Nurses Working in a Tuberculosis Hospital in South Africa: An Ethnographic Study ................................................................................................................................................. 52

Judith Parson ......................................................................................................................................... 53

Preventing type 2 diabetes after gestational diabetes ..................................................................... 53

6

Loujain Sharif

The development and evaluation of educational interventions with differential hypothesised mechanisms of action to reduce mental illness related stigma amongst undergraduate Saudi Nursing students This study draws upon the Medical Research Council's (MRC) new guidance framework for the development and evaluation of complex interventions in healthcare. In the Pre-clinical phase: a review of literature is conducted to explore the theory available on stigma to mental illness in general and on conceptual frameworks behind stigma and educational interventions used to reduce stigma to mental illness available to healthcare personnel in particular. Studies, which looked at tools that measured stigmatising attitudes and behaviour, are also reviewed in order to determine the outcome measures of choice for this study. In Phase 1: the chief components of the intervention are determined and tested in a pilot study, informal focus group sessions are held with the students following each intervention to discuss their views of the intervention. Their recommendations are taken into consideration and contribute towards the development of the second phase of the study where the exploratory trial is carried out. In Phase 2: the students are randomised into two conditions comparing the intervention to an appropriate alternative. The two conditions are: 1) PowerPoint lecture on stigma to mental illness, 2) Service user video lecture perspective on stigma to mental illness. Outcomes are measured at three different time (T) intervals; 1) baseline (T0), 2) immediately post the educational intervention and prior to clinical placement (T1), and 3) post clinical placement (T2). Finally, in Phase 3: qualitative interviews are conducted with an actively selected sample of students who demonstrate different patterns of outcomes, to identify the active ingredients in the interventions and a more elaborative account of their experiences.

7

Mary Sheridan

Use of case studies to identify strategies to support evidence based management of term breech pregnancies: Phase 2 of the ‘Think Breech’ UK study.

Background

Breech presentation occurs in 3-4% of term pregnancies, with 15-20,000 women in the UK each

year having a singleton breech presentation at term. Following publication of The Term Breech

Study, planned caesarean section (CS) is the preferred birth mode for many women and clinicians.

Although current RCOG and NICE guidance state External Cephalic Version (ECV) should be

available for all women with an uncomplicated breech presentation, a UK wide survey (phase 1 of

the Think Breech study) found limited compliance with recommendations.

Method

Following phase 1, two tools were developed to provide a summary score of compliance with best

practice recommendations for term breech presentation. Using these tools, three maternity units

with the highest scores were identified as ‘centres of excellence’. A case study of each centre was

conducted, informed by Yin (2008), to enable the PI to identify what worked for whom, when and

in what circumstances.

Data collection for each case study included: semi-structured interviews with staff and collection

and review of documents e.g. blank maternity notes, clinical guidelines and patient information

leaflets. Data were analysed using The Framework approach.

Results

Several factors were identified in common across the centres: how units value and apply research

evidence for the management of breech presentation at term, development and regular audit of

care pathways to promote ECV and strategies to support women, their partners and staff to offer

vaginal breech birth.

Discussion

ECV at term is poorly implemented and poorly defined, suggesting many women undergo

unnecessary CS birth. Phase 2 findings enabled strategies to promote ECV and support for vaginal

breech birth to be identified.

Conclusion

Increased promotion and use of ECV could reduce planned caesarean births for breech

presentation. Maternity services should explore strategies to support vaginal breech births when

ECV is unsuccessful or the breech presentation is diagnosed in labour.

8

Petra Stolz Baskett

Needs assessment in caregivers of older cancer patients using the German version of the Supportive Care Needs Survey for Partners and Caregivers (SCNS-P&C44)

Objectives: To present data on the translation, discriminatory potential, psychometric properties and none-response issues related to the SCNS-P&C44 (German version).

Method: A consecutive sample of informal caregivers (n=86; aged 37-85), of older chemotherapy patients were recruited from three ambulatory cancer clinics in north-eastern Switzerland. The SCNS-P&C44 was translated from its original English version into German following common procedures for cultural adaptation of research instruments, i.e. multiple forward translation, translator agreement and piloting. None response was assessed and internal consistency measured using Cronbach’s alpha for the proposed subscales.

Results: Respondents reported up to 41 moderate to high needs, with 24 participants (28%) reporting no moderate to high needs at all. Cronbach’s alpha for the proposed underlying factors ranged from 0.91- 0.97, indicating good reliability. Caregivers with depressed mood (p=.001) had significantly more often one or more moderate to high needs with an additional gender difference approaching significance (p=0.55). Non-response to single items appeared at random apart from the item ‘Fertility problems in patient’, which was missing for six of the cases (7%).

Conclusions: The German version of the SCNS-P&C44 appears to be a reliable tool to assess informal caregivers of older cancer patients’ needs indicated by high Cronbach’s alpha values. Associations of gender and mood state with need level add evidence to construct validity. Items assessing needs around fertility may be culturally or population specific and warrant further exploration in a larger study.

9

Petra Stolz Baskett

Qualitative exploration of experience and needs of informal care givers of gerontology-oncology patients undergoing ambulatory chemotherapy. Objectives: To understand and describe experiences and needs of informal caregivers of older cancer patients receiving parenteral chemotherapy. Methods: Semi-structured face-to-face interviews were conducted with informal caregivers (n=19) of patients 70 years and older receiving chemotherapy. Interviews were transcribed verbatim and analysed using the Framework approach to thematic analysis. Setting: Three ambulatory cancer clinics in the German speaking part of Switzerland, during 2011-2012. Results: Caregivers experienced manifold negative and positive emotional, spiritual, physical and social needs. Frequent issues of concern were the psychological impact of diagnosis, such as shock or disbelief, treatment side-effects, difficulties communicating with health care professionals, including the perception of long waits between tests and being told results, and thoughts about death/dying or loss respectively. Positive experiences included, for example, a sense of gaining valuable life experience and deepening of relationships. The patient’s age made some experiences appear normal to caregivers rather than cancer dependent. Caregivers were subsequently categorised: caregivers with needs that have been met by the Health Care Team (HCT); caregivers with unmet needs; and caregivers declining support from the HCT; as well as caregivers for whom more than one of these scenarios applied. Conclusions: Caregiver needs were mostly articulated around emotional, social and spiritual issues. Not all caregivers accepted support for their needs from the health care team. In summary, caregivers of older cancer patients vary in the level of support needed and individual and on-going assessment of informal caregivers needs is required in order to ensure the provision of adequate and appropriate support.

10

Suzanne Bench

The feasibility and effectiveness of user centred critical care discharge information to enhance critical illness recovery Introduction

Discharge from critical care can cause high levels of anxiety in patients and family members.1 Effective information may reduce this anxiety and promote recovery2, but the best way to provide this is unproven.

Objectives

To evaluate whether, in comparison to usual care, a User Centred Critical Care Discharge Information Pack‘ (UCCDIP), which included a patient discharge summary written by the critical care nurse3 would: (1) Improve patients’ and relatives’ psychological well being (2) Improve the discharge experience and (3) Be a feasible intervention to deliver in critical care.

Methods

Using a single centre cluster RCT, 158 patients being discharged from 2 critical care units (8 August 2011-21 May 2012) and a nominated relative (n=80) were randomly allocated into one of three study groups: (1) UCCDIP (2) ICUsteps booklet (3) Ad-hoc verbal information. The primary outcome (anxiety/depression) was measured 5 and 28 days after discharge. A questionnaire survey elicited the experiences of patients (n=126), relatives (n=48) and nurses (n=170) and identified feasibility issues. Data were analysed on an intention to treat basis with statistical significance set at p<0.05. Three investigators rated the quality of discharge summaries with inter-rater reliability assessed using a weighted Cohen’s Kappa. Qualitative data underwent thematic analysis.

Results and conclusions

No differences in anxiety/depression were demonstrated between study groups, but patients who received written information worried less than others about going to the ward. Sixty seven (54%) patients reported little/no understanding of what happened in critical care. Asking critical care nurses to write a discharge summary was feasible and considered valuable by patients, relatives and nurses. UCCDIP and in particular, the discharge summary has the potential to help patients understand their critical care experience, a first step towards recovery3.

References: 1. Bench et al (2010) Int J Nurs Stud 47(4):487-99 2. NICE (2009) Rehabilitation after critical illness. www.nice.org.uk 3. Bench et al (2012) Intens Crit Care Nurs 28(2): 123-31 Grant acknowledgements This report presents independent research commissioned by the National Institute of Health Research (NIHR) under its Research for Patient Benefit Programme (Grant reference number PB-PG-0110-21026). The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the Department of Health.

11

Yu Chen

Validity and reliability of the modified Chinese version of the Older People's Quality of Life Questionnaire (OPQOL) in older people living alone in China Background Quality of life (QoL) of older people has attracted much research attention in the context of demographic transition. An appropriate measurement tool is important to assess older people’s QoL. The OPQOL is a multi-dimensional QoL instrument which was developed from the views of older people and has been validated in England. However, it has not been used or tested in China where the number of older people living alone is increasing. Aims To test the validity and reliability of a modified Chinese OPQOL among older people living alone in China. Methods The OPQOL was translated and modified prior to being administered to a stratified random cluster sample of 521 older people living alone in Chongming County, Shanghai. Validity was assessed through construct, convergent and discriminant validity. Reliability was assessed through internal consistency and two-week test-retest reliability. Results Exploratory factor analysis indicated eight factors accounting for 63.77% of the variance. The factor structure was similar to the original version. However, some of the differences reflected the culture differences between China and England. Some items showed loading problems. The correlations between the scores for the OPQOL and Activities of Daily Living Scale, Social Support Rate Scale and UCLA Loneliness Scale were -0.50, 0.49 and -0.53 which supported the convergent validity. The mean ranks for the OPQOL and its dimensions were higher in the non-depressed group than the depressed group which confirmed the discriminant validity. The Cronbach’s α coefficient was 0.90 for the total scale and over 0.70 for most of its dimensions. The intra-class correlation coefficients of the scale and its dimensions ranged from 0.53 to 0.87. Conclusions The modified Chinese OPQOL has acceptable validity and reliability as a useful instrument to measure the QoL of older people living alone in China, although further testing to inform refinement is required.

12

Yu Chen

An exploratory study of quality of life of older people living alone on mainland china

Purpose: There is a growing population of older people living alone within the context of dramatic

population ageing and changing living arrangements. However, little is known about the quality of

life (QoL) of older people living alone in Mainland China where collectivism and filial responsibility

are emphasised. This study aimed to investigate the QoL and its related factors among Chinese

older people who live alone.

Methods: A stratified random cluster sample of 521 community-dwelling older people aged 60 years

and above and living alone in Shanghai completed a structured questionnaire through face-to-face

interviews. QoL was measured using the Older People’s Quality of Life Questionnaire (OPQOL).

Other data collected included self-rated health, physical health, cognitive function, depression,

functional ability, loneliness, social support, physical activity, health services satisfaction,

satisfaction with overall dwelling conditions and socio-demographic variables.

Results: The QoL of older people living alone in Mainland China was relatively low. Multi-way

analysis of variance (ANOVA) showed that satisfaction with overall dwelling conditions, self-rated

health, functional ability, depression, economic level, social support, loneliness, previous

occupation and health services satisfaction were predictors of QoL, accounting for 68.8% of the

variance. Additionally, depression and previous occupation had an interaction effect upon QoL.

Conclusions: Older people living alone in Mainland China were a vulnerable group to a lower QoL.

Identifying factors related to the QoL of this group of population could help health and social care

providers and policy makers to develop appropriate interventions to improve their QoL.

13

Jason Gray

Activities and Interventions of nurses in A & E Departments.

Background: Children account for a quarter of all attendances to A & E Departments each year in the United Kingdom. This number continues to rise with over 4.5 million during 2010/11. However, ensuring safe and effective systems of care are complicated by the absence of a skilled workforce who have the appropriate training and experience to care for this group. Understanding the activities and interventions of nurses is therefore important if we are to train a workforce who can deliver safe care competently and economically.

Method: A multi-method study was conducted comprising a literature review, a Delphi survey and semi-structured interviews with service users and providers. The Delphi survey recruited 21 experts who were selected because of their particular knowledge in emergency care. This was followed by semi-structured interviews with 18 RNs working within A & E Departments along the South-East of England and 16 parents/carers attending a children’s A & E Department.

Results: A total of 26 nursing activities and interventions were identified as important by the expert panel and were predominately associated with the care of the sick and injured child, pain assessment and medicines management. The activities and interventions reported by RNs during the semi-structured interviews concentrated on the initial assessment of the sick and injured child, communication and clinical skills such as resuscitation, medicines management and pain control. Parents reported communication as the most important nursing activity, followed by patient assessment and distraction techniques.

Conclusion: The ability for the RN to undertake a comprehensive assessment of the sick and injured child on their arrival at an A & E Department and completion of technical interventions was the activity deemed most important by clinicians. In contrast, parents reported that communication was more important than all other activities and interventions.

14

Rosamund Snow

The role of patient expertise inside and outside the health system: patient education in diabetes

Increasing emphasis is being put on making patients more responsible for their own health, with formal courses teaching people with long-term conditions how to be self-managing ‘Expert Patients’. Research on patient education has looked mainly at cost-effectiveness and medically-defined outcomes. This study explores several unaddressed areas: the role created for the patient during education, what it means to take part, and consequences for patients’ lives long-term. Focusing on DAFNE (Dose Adjustment for Normal Eating), an international programme for Type 1 diabetes, it is one of the first studies in the field to be entirely service-user led.

A qualitative approach was taken, using narrative analysis and informed by disability theory. Participants were recruited from established education centres in three English NHS hospitals. Eleven new students were interviewed pre-course, observed during education, and re-interviewed three months later. Retrospective narratives were collected from ten former students. Data was gathered from 32 interviews and 146 hours of observations, including five days of complete participation in DAFNE by a diabetic user-researcher.

Most students found their experience of DAFNE positive, speaking about lifestories transformed. Metaphors of chaos or imprisonment changed to those of control, freedom, and pride, particularly for those who had been given inadequate, outdated or incorrect information pre-course.

However, in interactions with the health system, obstacles to self-management arose when healthcare professionals were uncomfortable with patients’ new expertise. Personnel with the greatest power over medication supplies tended to be those with the least condition-specific knowledge, resulting in tension when Expert Patients required things that their primary care team deemed unnecessary.

The course reinforced the concept that the main obstacle to a healthy body was personal motivation, something students accepted despite being given almost unreachable biomedical targets. This led to some positioning their self-management work as failure, even when they had better-than-average health outcomes.

15

Wladzia Czuber Dochan

Researching patients’ experience: challenges of analysing qualitative phenomenological data using Moustakas’ method and NVivo software

Background: The dominant notion of descriptive phenomenology is that of essences, referred to as ‘the essential, invariant structure’ of a phenomenon and ‘returning things to themselves’, which constitute the conscious perception of human experience. A descriptive phenomenological study aims to present the experience in both the textural (what is it?) and the structural (what does it mean?) form, reflecting the experience of each participant taking part in a study (Moustakas 1994).

Aim: To explore the process of qualitative data analysis utilising Moustakas’ method and to analyse the challenges it presents when using NVivo software.

Methods: The lived experience of fatigue in people with inflammatory bowel disease (IBD) was derived from 20 in-depth unstructured interviews conducted over four months. A modified eight step Moustakas’ method was employed to analyse the data. The NVivo 9 software was used to manage data (Bazeley 2007).

Results: Moustakas’ method allowed for description of the individual’s experience of IBD-fatigue with its textures and structures, as well provide a composite description of the experience of the group. NVivo assisted in storing the data for each individual participant as well as data under each code and theme, making data management and retrieval easier. It did not however present all data at once with its themes and codes and other methods of data presentation were required.

Conclusion: Moustakas presents data in a linear way; it however by no means involves a linear process of analysis. The analysis involved an iterative process at different stages and was very repetitive and time consuming, but contributed to a full immersion of the researcher in the data, which allowed for the full description of peoples’ experience. NVivo is good for managing data; however at times it was necessary to employ other, more visual ways of data display to ‘see’ its complexity and inter-relations.

References:

1. Bazeley P (2007) Qualitative data analysis with NVivo. Sage, London

2. Moustakas C (1994) Phenomenological research methods. Sage, London

16

Heather Jarman

A qualitative study of emergency nurses’ experiences of working in a reconfigured major trauma system This study explores the experiences of clinical nursing staff working in the Emergency Department of a Major Trauma Centre (MTC) with regard to the restructuring of trauma services, particularly the impact upon their own work situation and practice.

Background

There has been considerable investment in the development of trauma care delivery in the UK in recent years culminating in widespread reconfiguration in 2012. Whilst there is a body of literature on trauma care delivery, this focuses largely on patient outcomes and clinical interventions. The effect of such changes on the work situation of those in this setting is yet to be determined and there is limited investigation of the impact of service restructuring on practices in the MTC.

Methods

The views of nurses toward major trauma care are explored through a focused ethnographic approach, including participant observation and interviews. This enabled insights and understanding to be gained within the specific cultural context of a Major Trauma Centre. A total of 27 hours of participant observation was undertaken over a period of 5 months, concurrent to this 15 semi-structured interviews using a topic guide were conducted.

Analysis of data was undertaken using content analysis.

Findings

The data describes the field setting of the MTC and more specifically the events surrounding a ‘major trauma call’ event. Analysis of fieldwork data revealed three main themes a) Nurses perceptions of major trauma work; b) the “decent” trauma patient; and c) “Being put on a pedestal”.

17

Maggie Tarling

The characteristics of safety climate in different acute adult nursing practice settings: Preliminary results There is growing evidence that organisational safety culture is related to quality outcomes (Freeth et al, 2012) and emerging evidence from the USA indicates that there is a gap in understanding the sources of variation in safety culture measurement (Pronovost & Sexton, 2011). The Safety Climate Questionnaire was developed in the petrochemical industry within the UK (Cox & Cheyne, 2000) and although it has been used in the UK health sector (Currie & Cooper, 2008) its factor structure has not been tested in a healthcare population. The aim of this study was to test the factor structure of the Safety Climate Questionnaire with qualified nurses and determine whether safety climate varied across a range of clinical settings.

Methods

The Safety Climate Questionnaire was distributed to a convenience sample of qualified band 5 & 6 nurses working in acute hospital settings who were undertaking nursing courses at the school.

Results

A total of 291 questionnaires were completed (response rate = 57%). A Confirmatory Factor Analysis (CFA) was undertaken using SPSS AMOS and the results indicated a good fit (CFI = 0.812 p < 0.01) to the original nine factor structure. Further comparisons of safety climate scores between nurses working in different clinical settings indicated a statistically significant difference between groups as determined by one-way ANOVA (F = 4.095, p = 0.003). A Tukey post-hoc test revealed that there was a significant (p < 0.05) difference in scores for management commitment between operating theatre nurses compared with nurses working in ward settings, and a difference in scores for communication between critical care, operating theatres and medical wards. A series of focus group discussions are being undertaken to explore these differences in more depth.

References

Cox SJ & Chyene AJT (2000) Assessing safety culture in offshore environments. Safety Science. 34: 111- 129.

Currie L & Cooper C (2008) Measuring staffs’ perceptions of safety climate: testing The Safety Climate Questionnaire (SCQ) for use in healthcare: Final Report. London: RCN.

Freeth D, Sandall J, Allan T, Warburton F, Berridge EJ, Mackintosh N, Rogers M, Abbott S (2012) A methodological study to compare survey-based and observation-based evaluations of organisational and safety cultures and then compare both approaches with markers of the quality of care. Health Technology assessment. 16(25). Pronovost R & Sexton B (2011) Assessing safety culture: guidelines and recommendations. Quality & safety. 14(4): 231 – 233.

18

Louise Barriball

Evaluation of a Fast Track Health Visitor Initiative: The views of students, managers and practice teachers

Health visitors are key to the successful delivery of the Healthy Child Programme and protecting and safeguarding children and young people. The Fast Track Health Visitor Initiative was initiated in response to a number of national and London policy initiatives. This longitudinal evaluation focuses upon: (i) Fitness for purpose, (ii) Academic achievement and (iii) Student transition from different points of entry to Specialist Community Public Health Nursing (SCPHN) registration. The study focuses upon three transition points during student development as a health visitor: recruitment and enrolment; during the SCPHN programme; and early points during the SCPHN career. The sample comprises two groups of SCPHN students, those with no post-qualification experience and those with post-qualification experience. Data collection comprised: students (application forms, questionnaire, interview), managers (interview) and practice teachers (focus groups) in phase one; and students as newly qualified health visitors, preceptors and managers (interviews) in phase two. The qualitative data were thematically analysed and data from the student questionnaire were analysed using descriptive statistics This poster will present the findings of phase one, including enrolment and recruitment, progression through the SCPHN programme and at programme completion. These findings provide an understanding of the Fast Track SCPHN preparation from the perspective of students, practice teachers and managers. Initial analysis suggests that previous experience, either nursing work or life experience, is a key enabler regarding assimilation into the SCPHN role and that practice teacher support is crucial to the socialisation process. The contribution of previous experience needs further exploration as do the different needs of practice teachers supporting students with different profiles at enrolment on a SCPHN programme.

19

Mamdouh El-hneiti

An exploratory study of the nurse’s role in health promotion and cardiovascular disease in Jordan

Background. High rates of obesity, smoking and sedentary lifestyle have led to a high prevalence of

cardiovascular disease (CVD) in Jordan which was the leading cause of death in 2010 (WHO,

2012). The Registered Nurse’s role in promoting the health of the Jordanian population relating to

cardiovascular disease is unclear.

Aim. This study explores the role of the Registered Nurses in health promotion relating to

cardiovascular disease in Jordan.

Method. A cross-sectional questionnaire survey was conducted across acute care settings (medical

and surgical wards), primary healthcare centres and out-patient departments of general hospitals

(public sector, private sector and Royal Medical Services) in Amman. The total sample (n=1726)

(response rate 78.4%) comprised nurses (n=676), doctors (n=458) and patients ((n=592) derived

from cluster random sampling at the sector level and proportionate stratified quota sampling within

individual sites.

Findings. Across the total sample 29.8% reported undertaking regular physical exercise; 28.7%

were smokers; 14.1% past smokers and 57.2% non-smokers. There were varied views regarding the

role of Registered Nurses in health promotion relating to CVD across the different samples (nurses,

doctors and patients) revealing a lack of consensus regarding role legitimacy within health

promotion. CVD knowledge varied across the nurse sample with 47% having a high-level of

knowledge, 48% an adequate knowledge and 5% a low-level of knowledge. Nurses who did not

undertake physical exercise nor intended to undertake physical exercise reported less CVD

knowledge compared to other nurses (H=23.264, 3df, p<0.001). Univariate analysis revealed that

there is a strong association between health promotion regarding cardiovascular disease by

Registered Nurses and two predictors (i.e. perceptions of exercise barriers and Stages of Change

relating to physical activity levels) with the following modifying factors: views of responsibilities for

health promotion; perceptions for health promotion; and perceived constraints to health promotion

(R Squared= 0.291).

20

Rebecca Blackwell

Geriatric-Only Emergency Room in New York: Fieldwork Informing an Experience-Based Co-Design study of palliative care for older people in the Emergency Department in the UK through a Florence Nightingale Foundation travel scholarship

Background: Increasing numbers of older people with long-term conditions cancers and co-morbidities are putting pressure on Emergency Departments (EDs). Use of EDs may be triggered by disease exacerbation or progression, patient or carer anxiety, and unavailability of other services; in this context ED interactions can be distressing for patients, carers and staff alike. In the US, innovative responses to this problem include Geriatric-Only Emergency Rooms.. Findings from a fieldtrip to a Geriatric-Only Emergency Room in the US inform an Experience-Based Co-Design study that aims to improve ED interactions for older patients, their carers and staff.

Aim: To conduct fieldwork at Mount Sinai Hospital, New York, exploring the development of care for older people in the ED and extrapolating key lessons for the UK.

Methods: Qualitative data collection was conducted within the main ED and the Geriatric-ED (a separate room, designed and operating differently to the main ED) over one month. Data were collected over 140 hours in the field through field notes and photographs from observations, informal interviews with staff, researchers, patients, carers and staff training sessions. Data were analysed thematically.

Findings: These include four key domains informing the development, success and challenges of the Geriatric-ED: Organisation Operations, Resources and Pathways, Staff Experiences, and Patient/Carer Experiences.

Key Findings:

• Environmental changes to reduce patient deterioration included soft lighting, thick mattresses,

wide bed spaces, hand-rails, large-print paperwork and clocks

• Provision of distresses and delirium-reducing resources, included reading glasses, hearing aids,

and stress-balls

• Adapted pathways to identify age-related challenges were implemented into general

assessments e.g. dementia, frailty, falls-risk, social support, carer fatigue

• Early involvement of patients/carers in identifying problems and developing strategies and staff

support is vital

• Successful service redesign for older people within the traditional ED has modelled the

paediatric ED services approach

21

Wei Zhang

Nurses' attitudes toward the information and communication technology in the healthcare delivery system: A systematic review

Background: As the largest component of the healthcare workforce, nurses’ attitudes toward

Information and Communication Technology (ICT) are an important part of the overall evaluation

of the successful implementation of new ICT. In many studies pre-dating 2000, ICT was often

viewed as dehumanizing, confusing and ‘uncaring’ by nursing staff. As modern health care delivery

is moving from the “face to face age” to the “information age”, it is unclear what attitudes nursing

staff have toward ICT and its facilitators and inhibitors.

Objectives: Describe nurses’ attitudes toward ICT within healthcare delivery and the factors

underpinning these attitudes.

Methods: A comprehensive search of 8 databases covering English and Chinese language

publications since 2000 was undertaken using a combination of terms.

Results: The final review identified 40 studies. Nurses’ attitudes toward ICT varied. A range of

variables have been examined as potential factors influencing nurses’ attitudes with gender, age and

education level being investigated most frequently but none were consistently associated factors.

Previous experience with computer, computer knowledge/skills, education and training were

associated with more positive attitudes toward ICT. Poor experience of the software design and

functionality of the ICT systems in use were associated with nurses’ negative attitudes.

Conclusion: Overall, the attitudes of nurses toward ICT varied widely with attitudes toward ICT

tending to decline after an ICT system implementation with the poor design and inadequate

training being criticized. Nurses’ previous experience with computer appeared to be a consistent

factor underpinning more positive attitudes.

Implications for nursing practice

The evidence indicates that ICT implementation has yet to fully reach expectations. The need for

appropriate ICT training and ‘suitable for use’ software emerged as key variables suggesting that

organizations need to plan carefully when proposing the introduction of ICT into nursing practices.

22

Lallita Carballo

Multidisciplinary clinical decision making in colorectal cancer teams: A mixed method, multi stage investigation into the contribution of the clinical nurse specialist within the multidisciplinary team meeting. Background: Multidisciplinary teams (MDTs) are considered central to the delivery of high quality cancer care and decision-making is their key function. Core members of the multidisciplinary team are typically surgeons, oncologists, radiologists, pathologists and clinical nurse specialists. Little is known about the effectiveness of the multidisciplinary team clinical-decision making process and emerging evidence suggests that there is variation in participation by different professions, in particular, by the clinical nurse specialist.

Objective: The research sought to, firstly, explore the nature of the clinical nurse specialist contributions to discussion at multidisciplinary team meetings and, secondly, investigate the factors that enable and inhibit clinical nurse specialists from bringing a patient-centred perspective to bear on decision-making processes at such meetings.

Design: A mixed method, multi stage and multi site investigation was used to collect data for the study.

Setting: Data were collected from four multidisciplinary colorectal cancer team across four acute NHS Trusts in London.

Participants: Participants included all multidisciplinary members from the colorectal cancer teams.

Methods: Data were collected over three phases and included; structured observation of twenty MDT meetings; semi-structured interviews with twenty core MDT members; and a focus group with all clinical nurse specialists.

Results: Phase one of the study commenced in April 2013 and data collection is scheduled to complete by July 2014.

23

Asmah Husaini

A metasynthesis of the roles of nurses in providing end of life care for cancer patients

The aim of my PhD research is to explore the role of palliative care nurses in providing end of life

care for terminally ill cancer patients in Brunei Darussalam. Many research studies have discussed

the importance of nurses in delivering palliative care (May 1995, Clarke 2000, Payne et al 2009).

Nurses are the frontline caregivers for those nearing the end of life and their main role is to optimise

patients’ quality of life (Cummings 1998, Woods et al 2000). There are many national and

international guidelines developed to assist nurses in caring for terminally ill cancer patients, but

few are specific to nursing care. Furthermore, there is limited research on palliative nursing care for

cancer patients. The medical status of the patients and the ethical issues surrounding the

recruitment of this group of patients as research participants have been identified as among the

barriers to palliative nursing research (Lee and Kristjanson 2003). There are however many smaller

scale qualitative studies carried out with the aim to explore and understand the role of nurses in

providing palliative care for cancer patients. This paper presents a meta synthesis carried out using

the meta ethnography approach developed by Noblit and Hare (1988) to synthesise the findings of

qualitative studies carried out to explore the role of nurses in providing end of life care for cancer

patients. This meta synthesis will give a clearer picture towards the roles of palliative care nurses in

providing end of live care for cancer patients

References:

Clarke D. (2000) Palliative care history: a ritual process. European Journal of Palliative Care. 7(2), 50-55. Cummings, I. (1998). The interdisciplinary team. In Oxford Textbook of Palliative Care (2nd ed) (Doyle D.,Hanks G. & MacDonald N. eds.)pp 19-30. Oxford Medical Publication, Oxford UK. Lee S. and Kristjanson L. ( 2003) Human research ethic committees: issues in palliative care research. International Journal of Palliative Nursing. 9(1), 13-18. May C. (1995) ‘To call it work somehow demeans it’: the social construction of talk in the care of terminally ill patients. Journal of Advanced Nursing. 22(3), 556–561. Noblit GW and Hare RD (1988) Meta- ethnography. SAGE, Newbury Park, London. Payne S., Ingleton C., Sargeatn A. and Seymour J. (2009) The role of the nurse in palliative care settings in a global context. Cancer Nursing Practice. 8(5), 21- 26. Woods S., Beaver K. & Luker K. (2000) Users’ views on palliative care services: ethical implications. Nursing in Ethics. 7, 314–326.

24

Virginia La Rosa Salas

Combining motivational and volitional interventions to promote healthy behaviours: a web based RCT Objective: To compare the effectiveness of an online motivational intervention (MI) based on the Theory of Planned Behaviour (TPB) to the same intervention augmented by a volitional intervention (VI) based on implementation of intentions to increase physical activity and consumption of fruit and vegetables.

Design: 4-arm randomised controlled trial.

Method: The study involved three waves of date collection over a 5-months period, incorporating an experimental manipulation of TPB variables and implementation intention intervention at time 1. Participants (N=2896) were randomly allocated to either the physical activity or the fruit and vegetable study groups. Participants in each group (N= 1448) were allocated to one of four conditions. Cognitions and PA and F&V consumption was measured at baseline and at 1 month and 4 months follow up.

Results: In the physical activity study the MI caused a significant increase (p= 0.005) in the behavioural beliefs 4-month follow-up but no other cognitions or behaviour were increased. Intention was not modified however scores at baseline demonstrated a ceiling effect, i.e. scores were high at baseline which provided little opportunity for an increase over time. In the fruit and vegetable study the MI also caused a significant increase in behavioural beliefs (p= 0.04) at 1 month follow-up. Moreover, the MI caused a significant increase in the number of portions of vegetables consumed per day (p= 0.01). Neither the physical exercise level nor fruit and vegetable consumption were improved by implementation intentions.

Conclusion: The results suggest that to increase physical activity and fruit and vegetable consumption among undergraduates it is needed to change their behavioural beliefs. The MI reported here may present an inexpensive solution to the problem of unhealthy behaviours adopted by young adults. These results suggest the value of the TPB in the design of effective interventions to change health behaviours. However, the VI was ineffective in changing behaviour.

25

Sarah Jane Besser

Developing and testing a psychological intervention to promote adherence to osteoporosis treatment: a case series approach

Background Osteoporosis is a common condition of bone deterioration, which results in an increased risk of fracture. Although medication can reduce the fracture risk, patient adherence to treatment is low. The study design was multiple cases with multiple units of analysis, guided by the Medical Research Councils (MRC’s) framework for the design and evaluation of complex interventions. Improving medication-taking is an important goal for the NHS because it can improve medication effectiveness.

Objectives The aims of the study were to assess the effectiveness of a multifaceted psychological intervention in changing adherence to osteoporosis medication, illness representations, (expressed both verbally and visually through drawings) and to investigate patients’ subjective experiences of the intervention. Representations of illness were informed by two theoretical frameworks, and focused on both cognitive and emotional representations of illness.

Methods The participants were 8 women prescribed strontium ranelate for osteoporosis, who were identified as non-adherent. They received a multifaceted intervention; tailored educational material, motivational interviewing and guided problem-solving over a 3 month intervention period. Adherence and beliefs were assessed at monthly intervals for 4 months, by a researcher who was blind to the intervention. Patients were followed-up 1 month post intervention. Patients were also asked to draw how they visualised their condition before and after the intervention.

Results Preliminary results for 2 cases will be presented, with analysis of changes within participants in beliefs, emotions and adherence throughout the intervention. Visual representations of the condition will also be presented.

Discussion Data shows that patients responded well to the intervention, with a marked increase in adherence. Evaluation indicates that the intervention was worthwhile. This intervention has the potential to increase treatment adherence. The next step is to test the intervention in a randomised controlled trial.

26

Kathy Swanzy-Asante

Challenges of recruiting to a study about compassionate care in acute mental health care setting

Aim: The overall aim of the study is to explore the perceptions of service users, carers, registered nurses and health care assistants about compassionate care in acute mental health care settings.

Objectives: The objectives of the study are to explore what service users and carers perceive to be the meaning of compassionate care; explore nurses perceptions of compassionate care including factors which enable or hinder the delivery of compassionate care; identify processes which can help to embed compassionate care in practice and develop a model of compassionate care in acute mental health care settings.

Background: Compassionate care has become a national priority in the National Health Service (NHS) in the United Kingdom due to concerns about poor quality of care and recent high profile reports highlighting the lack of compassion in nursing. Although there are political and professional drivers promoting compassionate care, exactly what compassion means and how it can be delivered in clinical settings is unclear. Compassionate care could become meaningless and a rhetoric if the term and processes for the delivery of compassionate care in practice are not clarified.

Design: The study is a qualitative approach using a purposive sample of 15 service users, 10 carers, 10 registered nurses and 10 health care assistants drawn from an acute mental health unit comprising 3 acute wards in an inner London NHS Foundation Trust. Data will be gathered using semi-structured interviews with the service users and 3 separate focus group discussions with carers, registered nurses and health care assistants. Framework data analysis method will be used to analyze the data generated.

Challenges: Recruitment of service users and carers has been a difficulty due to short length of stay and early discharge on the acute wards. Several approaches have been used to address the recruitment problem.

Conclusions and implications: The study could help to clarify the meaning of compassionate care in acute mental health settings from service users’, carers’ and staff perspectives and contribute to the development of a model of compassionate care within acute mental health care settings.

27

Angela Parry

An exploration of the literature on Registered Nurse medication administration error

Background: Medication administration errors are a leading cause of patient safety incidents resulting in untoward harm, and death (Cousins et al, 2012). Despite international and national policies driving local initiatives reported medication administration error rates are not abating.

Objective: To explore the factors contributing to Registered Nurse (RN) medication administration error (MAE).

Methods: A systematic search of 6 electronic databases was undertaken from 1 January 1999 - 31 December 2012. Inclusion criteria were studies published in peer reviewed journals; reported primary research in acute adult hospital settings within developed healthcare systems; and focused on RNs and factors contributing to MAE. 26 English language papers were selected and reported studies conducted in 4 continents, 11 individual countries, with one multi-national study incorporating 27 countries. Different study designs precluded a meta-analysis, therefore the literature was analysed using two distinct frameworks: Donabedian’s (1988) quality assurance framework was used to explore the concept of RN MAE; Bandura’s (1986) reciprocal determinism theory was used to explore the factors contributing to RN MAE.

Findings: Analysis revealed a lack of clarity and stability in how RN MAE was described and reported across studies, and its relationship to harm. Although a number of factors that could be considered under the person and environment domains of Bandura’s (1986) theory could be identified, the range of measures used made it difficult to identify the contribution of specific factors to RN MAE.

Conclusions and Implications for research and practice: A continued focus on exploring the factors contributing to RN MAE as a way of reducing patient harm is misplaced until there is a nationally and internationally accepted definition of MAE. An alternative way of understanding MAE is proposed which focuses on RN behaviour in the medication administration process. This offers a new lens for understanding this important patient safety issue.

References:

Bandura, A. (1986) Social Foundations of thought and action. Englewood Cliffs NJ: Prentice Hall.

Cousins, D., Gerrett, D,. Warner, B. (2012) A review of medication incidents reported to the National Reporting and Learning System in England and Wales over 6 years (2005-2010) British Journal of Clinical Pharmacology 74 4 597-604.

Donabedian, A. (1988) The quality of care: How can it be assessed? JAMA 260 12 1743-1748.

28

Veronica Zuccolo

Women’s decisions and experiences about infant feeding - a longitudinal qualitative study Context: There is limited evidence of how UK women make decisions about infant feeding in the shorter and longer-term. In 2010, 83% of women in England initiated breastfeeding, however less than 1% exclusively breastfed until 6 months, the period recommended by WHO and Department of Health England. The aim of this longitudinal grounded theory study was to explore and understand influences and context on women’s experiences of decision making about infant feeding from pregnancy until 6 months post birth.

Methods: Ten women attending for antenatal care at one London hospital were recruited. Semi-structured interviews were conducted with women during pregnancy, at 4 to 6 weeks and 3 and 6 months post-birth. Three partners were also interviewed at 4 to 6 weeks post-birth to explore their contribution to infant feeding decisions.

Results: Emerging themes, identified using constant comparative analysis, were identified, which recurred cyclically: expectation, emotional labour, adaptation and reassurance. Expectation, where women postulated what infant feeding, infant care, and access to formal and informal support would be like. Emotional labour, illustrated how women struggled with their experience to ensure their infant’s wellbeing. Infant’s needs were prioritised while women mostly neglected their own perceived needs. Adaptation refers to women’s use of strategies to gain knowledge and overcome barriers to regain control over decision making. In the reassurance phase, women reflected that they had done the best they could for their infant and consequently regained control. Implications for policies and practice: Women’s decisions were concomitant to infant feeding decisions, and reflected their postnatal experiences, expectations, needs, perception of their infants’ needs and availability of support. These insights support the need to develop effective and individually tailored interventions based on women’s needs, to promote and optimise their decisions about infant feeding longer-term, and incorporates advice on infant feeding and sleeping behaviour.

29

Simon Walne

How nurses manage interruptions in dynamic environments

Introduction: Health professionals in a range of settings are interrupted frequently, and this may lead to errors. Interruptions have been framed as isolated events where individuals are forced to switch from a ‘primary’ task to a ‘secondary’ one. Health professionals have thus been viewed as ‘passive recipients’ of interruptions, and remembering the interrupted task has been seen as the key issue. The current study examined how nurses actively managed interruptions. It aimed to develop a deeper understanding of interruptions and the strategies nurses used to handle them.

Method: Unstructured observations and semi-structured interviews of nurses were conducted in three settings: 1) a Day Chemotherapy Centre, 2) A&E, and 3) a Surgical Ward. The researcher made detailed notes on a smartphone. Interviews explored nurses’ perceptions of the work environment and strategies used to manage the workflow.

Results: The study found that nurses faced frequent interruptions, from a variety of sources. Nurses were often managing multiple tasks when interrupted, not just a single ‘primary’ task. Nurses’ tendency to multitask, together with other aspects of the work context (e.g. task characteristics and the physical environment) shaped how they handled interruptions. Rather than always switching immediately after interruption, nurses switched at appropriate and convenient times, and used other strategies, such as delegation, to manage these events. They also planned and prioritised their work, and used a variety of tools (e.g. medical records), strategies (e.g. routines) and processes (e.g. teamworking) to manage cognitive demands and support multitasking.

Conclusion: Rather than being solely concerned with managing the interruption, nurses were concerned more generally with maximising the efficient use of resources – including their own time – to manage the multiple, competing demands. Nurses’ planning and prioritizing, together with their use of tools and strategies, and the distributed cognition, demonstrated that managing interruptions was more complex than simply remembering the interrupted task. By switching at convenient times, and by using other strategies (e.g. delegation), nurses gained control over their work. They might therefore be better characterized as ‘active managers’ of interruption rather than ‘passive recipients’. Those interested in designing safer healthcare systems might take more account of the context of interruptions.

30

Jacqueline Sin

Credibility vs anonymity: Views of siblings of young people with psychosis on a web-based educational and peer support intervention Background: The onset of first episode psychosis (FEP) peaks around late teenage and early adulthood years. It is well known that siblings are often the only age-appropriate peers and the most natural agent to promote recovery in the young people with FEP.1 A small but coherent body of research has highlighted siblings’ needs for robust and flexible educational and peer support resources as many are in a busy phase of their own lives.2 However, little research evidence was available to inform the intervention design.

Objectives: The aim of this paper is to report the findings from a focus group study with siblings so to describe their views on the design, content and considerations for developing a specific web-based intervention.

Methods: Focus group methodology was used to explore a range of perspectives gained through discussion among 14 siblings in three groups.

Results: Siblings unanimously supported the development of a focused resource to address their specific needs using interactive health communication applications. Siblings suggested a number of content items for information-giving, some are unique to siblings’ needs, such as worries about genetic risks, dealing with adjustment and ‘survivor guilt’. They also highly valued an interactive peer discussion and support forum where siblings could share experiences in commonly encountered issues. Siblings emphasised the needs for professional inputs and moderation online to enhance the intervention’s credibility and security. A number of strategies to promote engagement were also proposed by siblings, including: regular email reminders and incentives.

Conclusion: The findings from the focus group study have informed the development of a web-based intervention entitled ‘The E Sibling Project’ (http://siblingpsychosis.org). The intervention aims to enhance siblings’ knowledge, coping and caring experiences and ultimately impact on their wellbeing. An online RCT is currently underway to test out the efficacy of this innovative intervention.3

Key references:

1Powell J., Martin S., Sutcliffe P., Todkill D., Gilbert E., Paul M. & Sturt J. (2010) Young People and Mental Health – The Role of Information and Communication Technology. Warwick: Warwick Medical School (Warwick Medical School Research Project funded by Comic Relief).

2Sin J., Moone N., Harris P., Scully E. & Wellman N. (2012) Understanding the experiences and service needs of siblings of individuals with first episode psychosis: A phenomenological study. Early Intervention in Psychiatry. 6: 53-59.

3Sin J., Henderson C., Pinfold V. & Norman I. (2013) The E Sibling Project – Exploratory randomised controlled trial of an online multi-component psychoeducational intervention for siblings of individuals with first episode psychosis. BMC Psychiatry. 13: 123.

31

Laura Nasir

Enabling multidisciplinary teams to span organizational and sectoral boundaries for the improvement of patient care Introduction: Patients often receive poor quality healthcare due to inefficient coordination between services, especially patients with long-standing and chronic diseases. Quality improvement has been linked to the success of interdisciplinary teamwork within organizations, but research is less clear about how integrating solutions across organizational and sectoral boundaries are enabled. Methods: A longitudinal nested case-study design was used with mixed methods to explore the extent to which the formation and facilitation of multidisciplinary ‘boundary-spanning’ teams enabled the integration of services for patients with highly prevalent conditions: (a) diabetes, (b) anxiety and depression, and (c) dementia. Areas with wide variations in local deprivation indices and care provision were specifically addressed. Data were collected for two years across a broad system of care in a diverse inner-city region of England. Interviews with patients and practitioners, observations of team meetings, online staff diaries and surveys, and secondary data analyses were used to examine the initiation, development, and delivery of innovative solutions for service improvement that crossed organisational and sectoral boundaries. Findings were examined for the extent of integration that emerged and the impact on patient care quality. Results: Team members of a local initiative tailored complex interventions through scheduled learning cycles and facilitated multidisciplinary stakeholder events. Solutions emerged to bridge chronic and acute disease services across perceived boundaries between primary care and secondary care, community, mental health, and specialist medical services. Tools for the analysis of knowledge creation and sharing processes across organizational and sectoral boundaries are presented. Facilitators and barriers to service improvement efforts for whole system care are described. Discussion: Despite identified challenges, practitioners, staff, and patients can be incorporated into service improvement efforts to identify local goals and outcomes for better integration of health care services.

32

Ranjita Dhital

Barriers and enablers experienced by pharmacists to delivering alcohol brief intervention. Introduction There is strong evidence to support the effectiveness of Brief Intervention (BI) to reduce alcohol consumption in primary healthcare. Alcohol BI has two components i) screening to identify risky drinkers; and ii) short motivating discussion to support reduction in drinking. Community pharmacies attract large numbers and a diverse range of people to a healthcare environment. However, community pharmacists’ experience of alcohol BI, remain relatively unexplored. Objective Identify barriers and enablers experienced by community pharmacists to deliver alcohol BI using focus groups.

Methods Community pharmacists (N = 27) were trained to deliver BI over five months (February-July 2010). Pharmacists’ experiences of the one-day training and delivering BI were evaluated using focus groups. Three focus groups were undertaken (September-October 2010). Each group comprised up to eight pharmacists: Group 1, seven pharmacists completed between 6-38 BIs; Group 2, six pharmacists completed between 2-6 BIs; and Group 3, eight pharmacists completed 0-2 BIs. Focus groups were audio-recorded and transcribed verbatim. The transcripts were coded and thematic analysis undertaken, using NVivo program to manage data.

Results Common themes identified from all groups were: role-plays with actors during training were considered helpful; BI paperwork should be simplified; BI should be designed to promote discussion; dedicated support-staff training; financial remuneration should be comparable with other pharmacy public health services. However, pharmacists (Group 3) who completed the least number of BIs suggested this service should be advertised nationally to increase customer awareness.

Discussion Pharmacists suggested BI should be designed to promote alcohol discussion with customers, rather than just providing structured advice and written material. Findings of this study were used to inform the design of the first two-arm randomised controlled trial assessing effectiveness of pharmacy BI (http://www.biomedcentral.com/1471-2458/13/152#B11). It is hoped these studies will contribute to current knowledge in the area.

33

Helen Jones

The organisational structure of the UK research nurse workforce in university NHS Trusts Aim - To examine the size and structure of UK clinical research nurse teams in NHS University Trusts .

Background - Clinical Research Nurses (CRNs) have become an established and intrinsic part of many multi disciplinary teams (MDT), partly due to the growth of a solid UK research infrastructure. However, the structure that CRNs work within has not been examined. There are sporadic local organisational reviews which generally remain unpublished. A single published review reported how implementation of a framework across an organisation resulted in a more cohesive system of CRN recruitment, management, training and governance (Ledger 2008). These reviews demonstrate individual pockets of work but no consistent approach or overall knowledge. This study will therefore seek to address this and carry out the first national review of the UK CRN workforce.

Method –A survey will be sent to Lead Research Nurses (n=48) across UK University Trusts as the majority of research (80%) is carried out in these organisations. The survey will be structured around a quality framework developed to identify factors (described as common challenges) associated with Quality Improvement in Healthcare (Bate et al, 2008). The framework identifies six common challenges centred on the influences of structure, politics, culture, education, emotions and technology.

Results - Both descriptive and parametric statistical analysis will be undertaken to provide a general description of the participants and to determine any specific associations between variables. Data may be stratified and analysed by some of demographic variables to provide additional information . The quality framework will be used to specifically examine how the six key challenges have been addressed within the workforce.

Conclusion- Findings from this study will provide information about the size and structure of the CRN workforce. This is part of a larger study and the data will be used to inform a case study phase of data collection examining four of the identified organisations in greater detail with the overall aim of identifying models of the research nurse workforce and best organisational practice.

References:

Bate, P, Mendel, P and Robert, G (2008) Organising for Quality, Radcliffe Publishing Ltd.

Ledger, T, Pulfrey, A and Luke, J (2008) Developing clinical research nurses. Nursing Management, 15, 2 pg 28 – 33.

34

Ben Hunter

Delivering health services through the private sector: experiences from a maternal health programme for low-income groups in northern India Background Governments worldwide are increasingly looking to private sector organisations to deliver public health services. Reasons vary: some want to develop competitive markets for services, others aim to extend coverage to underserved areas and groups. The ‘Sambhav’ scheme (meaning ‘anything is possible’) was launched in Uttar Pradesh, northern India, in 2011 to increase use of maternal and reproductive services by women living in urban slums. Vouchers are distributed in communities and women can use them to receive free services at accredited private hospitals. This presentation highlights some experiences from the scheme.

Methods Routine data on the number of services used were collected from voucher managers as part of a ‘realist’ evaluation of the Sambhav scheme in the city of Lucknow. Data were analysed using descriptive statistics. Semi-structured interviews were conducted in English or Hindi with 38 stakeholders, including programme staff, hospital managers and women service users, to explore their experiences with the scheme. Audio-recordings from interviews were transcribed and analysed thematically.

Findings Five years ago, half of the 86,000 births taking place annually in Lucknow were at home without a skilled attendant. At least 50 private hospitals provide elements of maternity care in the city however these were initially reluctant to join the Sambhav scheme. Intervention by the Indian Medical Association was necessary to generate interest and 17 hospitals have since joined. By April 2013 more than 24,000 Sambhav vouchers had been used in Lucknow. Dissatisfaction with pre-determined ‘below-market’ rates of payment to hospitals has dogged the scheme. Fixed rates for delivery, regardless of complications, have led to some incidents where women paid for complicated care, or else treatment was withheld and they were referred to other hospitals.

Conclusions Some private hospitals can be persuaded to participate in public health schemes for ‘below-market’ rates of reimbursement however safeguards are needed to prevent manipulation of referral systems.

35

Aniek Woodward

Medical training, professional trajectories, and the social contract in ‘post-conflict’ Sierra Leone What role does the medical profession play in ‘post conflict’ states? Many scholars have described the relationship between medical profession, society, and state as a ‘social contract’, with professionalism at its basis. Recently social contract theory has also informed some of the writing on health system strengthening in countries recovering from conflict. However, the reasons that young people enter medical training and the decisions they make after graduation are often complex. For example the newly trained doctors in this study work in a healthcare system dominated by unregulated private and non-governmental provision, live in a country with a large diaspora network, and possess qualifications that give them membership of an increasingly globalised and mobile workforce, all possible influences on their early career decisions. Moreover the extent to which young graduates recognise such a social contract themselves and the extent to which their careers trajectories are influenced by it have yet to be explored.

This doctoral research will adopt a qualitative longitudinal approach and will focus on Sierra Leone - a West African country that came out of conflict in 2002 with a damaged health system, depleted medical workforce and enormous population health needs. I aim to explore early career paths of medical graduates, using a series of individual and group interviews and a mixture of face-to-face and digital methods, ‘walking alongside’ them over a three-year period. The longitudinal analysis will focus on identifying the drivers of early career trajectories and choices in these early stages, and the motivations, allegiances and challenges that underlies these. I will also provide a detailed analysis of Sierra Leone’s medical training landscape, using documentary analysis and key informant interviews, to gain an insight into how planning, financing, regulation and training of medical doctors evolved after conflict. Results from this study will add to the knowledge on the medical workforce in post conflict settings and is likely to feed into future policy-making in this area.

36

Kathryn Dennick

Written emotional disclosure (WED) for adults with Type 2 diabetes: feasibility and preliminary effectiveness

To test the feasibility of written emotional disclosure (WED) for primary care patients with Type 2 diabetes. WED holds potential to address depressive symptoms in diabetes, yet its feasibility, and potential benefit, for primary care patients has not been established. Forty-one adults with Type 2 diabetes were randomised to WED (n=21) or neutral writing (n=18) (baseline mean ± SD (years): age 65.6 ± 9.9 and duration of diabetes 7.0 ± 6.2). Principal outcomes were feasibility of recruitment, compliance, acceptability and intervention fidelity. Potential benefit was assessed on between-group differences in depressive symptoms (CES-D scale), diabetes distress (PAID scale), diabetes self-management behaviours (SDSCA questionnaire) and perceived health status (EuroQoL) at three month follow-up. Statistical significance was determined using analysis of covariance. Recruitment was modest (6%), yet an unmet treatment need was identified. Fourteen intervention (61%) and 13(72%) control participants returned their writing, while 12 in each group (89%) then completed all sessions. Intervention fidelity was confirmed. Acceptability to patients was mixed. Exploratory effectiveness analyses suggested, relative to improvement in controls, WED is associated with a potentially clinically important worsening in depressive symptoms (p=.006) and non-significant trends for reductions in healthy dietary behaviour and perceived health status. There was no effect on other outcomes. The exploratory nature of the study, however, necessitates that the effects are interpreted with caution, and both the feasibility and potential benefit findings may be an artefact of the sample obtained. The evidence for the feasibility of WED in primary care diabetes was mixed, and in an unevaluated environment it may cause iatrogenic harm. On balance, WED is apparently not appropriate for use in this context in its current format. At most, further research with a more appropriate sample is required. The feasibility that was demonstrated and the unmet need identified suggest this may be a worthy endeavour.

37

Samantha Shaw

Developing and evaluating a brief online educational intervention for fostering nursing students’ compassion. Background: Despite the drive to cultivate compassion among healthcare staff, there is little

evidence-based research to support the education and development of compassionate attitudes or

indeed the best way to measure compassion in practice.

Aim: To produce and evaluate a brief online intervention for nursing students to foster compassion,

using best evidence in compassion research and positive psychology, and guided by the MRC

complex interventions (2008) framework.

Method: The pre-clinical first phase will identify potential interventions through literature reviews

to foster compassion in clinical and nonclinical populations and the available meausures to evaluate

such interventions. As part of this first phase, an online intervention will be built using a four stage

cycle, supported by advice from the advisory groups. The intervention will then be piloted for

usability by a sample of nursing students, and adapted and modified using this feedback. The

second phase will comprise an exploratory randomised study which will then evaluate the

acceptability, feasibility, preliminary effectiveness, and potential mechanisms of action the

intervention in nursing students within King's College London.

Results/Progress: To date, a review of the literature suggests a dearth of tools available to measure compassion or compassionate care in healthcare. Measures of compassion satisfaction, compassion fatigue, fear of compassion and compassionate attitudes towards self and others were located. However, although compassion satisfaction and compassion fatigue tools are well validated and used extensively, attitudinal measures of compassion are less well validated, and only one scale of compassionate care has been located. A second review is underway to examine education and training interventions which foster compassion in healthcare staff and community samples.

38

Maeve O’Connell

Midwives experience of using the carbon monoxide breath test for smoking cessation in pregnancy Background and Aim: Under-reporting of smoking status during pregnancy can contribute to low levels of referral to smoking cessation services. In 2010, the National Institute for Health and Clinical Excellence (NICE) advised the use of Carbon Monoxide screening by midwives as part of routine antenatal care for all pregnant women. However, it seems this strategy has not been widely implemented nor well received (Cope, 2011; O’Malley, 2010; Clift-Matthews, 2010). This study aimed to explore the lived experience of midwives that use Carbon Monoxide (CO) monitoring for smoking cessation in pregnancy and to investigate midwives attitudes to the use of CO Monitoring as part of routine antenatal care for pregnant women. Method:

A qualitative approach based on a descriptive phenomenology was employed. Ten midwives in the UK that use or have used the carbon monoxide breath test for smoking cessation at booking took part in the study. Semi-structured interviews analysed using Thematic Analysis.

Results:

Five main themes emerged: time constraints and the expanding role of the midwife, use of the CO test in practice, midwives acceptance, women’s reactions to the CO breath test, introduction of the CO breath test.

Key Findings and recommendations for practice:

Time constraints were reported as a significant barrier to implementation of the breath test as smoking cessation is competing with other equally important issues ie. screening of mental health and domestic violence in the booking appointment. Training and effective referral pathways are essential to ensure that health professionals using the test are not just performing it as a ‘tick-box exercise’.

Conclusions

The importance of having a clear referral pathway and support network with link Smoking Cessation Specialist Midwife to ensure smooth implementation of CO monitoring as routine practice was highlighted in this study. The Smoking Cessation Specialist midwife is a key support for both the midwives and women using the CO breath test.

Being sensitive, non-judgmental and performing the test with consent is essential to avoid women feeling guilty about smoking and be supportive of quit attempts. Regular mandatory updates in training are recommended to ensure that all staff using the monitor is competent. Training and involvement of HCAs and auxiliary staff is recommended to support the midwife in offering the breath test due to time constraints at the booking appointment. Further research is needed to determine the effectiveness of CO monitoring on smoking cessation.

39

Lesley Dibley

Coming out about Inflammatory Bowel Disease (IBD): transferable skills from the gay, lesbian, bisexual and transgender (GLBT) population in the UK

Background: within a UK study identifying the needs of GLBT people with IBD, we aimed to

identify how ‘out’ participants were about sexual identity and their illness, and determine whether

similar techniques are used to manage both pieces of information. Previous researchers have drawn

parallels between coming out about sexual orientation and chronic illness1,2. This original work

explored both issues in the same population.

Methods: we recruited GLBT people into a mixed methods online or paper survey. Phase 1:

demographic, degree of outness3 and coming out techniques data collected (analysed using Excel

and SPSS), with opportunity for free text responses (analysed using a simple coding technique).

Phase 2: participants interviewed about their disease-related needs (transcribed, thematic analysis).

Phase 1 data is presented here.

Results: 57 people took part (55 online, 2 on paper). 50 complete data sets included in analysis.

GLBT people use the same techniques for coming out about IBD and about sexual identity.

Although out to the same degree overall about both, they are more out about IBD to family than in

work or religious domains, and more out about sexual identity to family (except father) and work

peers than to work supervisors and religious contacts. Some people tell no-one about their sexual

orientation, but everyone tells someone about their IBD. Techniques include waiting for an

opportunity through which to share orientation and disease information. This was seen as necessary

to ensure understanding and support (for IBD) and to avoid misconceptions and embarrassment

(for sexual orientation).

Conclusions: These findings may help others manage the disclosure of their IBD diagnosis. The

coming out experiences and methods of GLBT people with IBD can inform nurse-led

development of information leaflets, providing helpful advice to anyone with IBD, regardless of

sexual orientation, for making information-sharing about IBD more effective and less stressful.

References:

Corrigan P, Larson J, Hautamaki J, et al. What lessons do coming out as gay men or lesbians have

for people stigmatised by mental illness? Community Mental Health Journal. 2009;45: 366-374.

Mohr J, Fassinger R. Measuring dimensions of lesbian and gay male experience. Measurement and

Evaluation in Counselling & Development. 2000;33: 66-90.

Myers,K. Coming out: considering the closet of illness. Journal of Medical Humanities. 2004;25:

255-270.

40

Lesley Dibley

Help-seeking for faecal incontinence in people with inflammatory bowel disease (IBD)

Background: Faecal incontinence (FI), a major issue for people with (IBD),1 remains a largely

unvoiced symptom2. We aimed to understand what influences help-seeking in people with IBD-

related FI, and what their desired support services are.

Methods: As part of a larger mixed methods IBD Continence Study (n=3264)3 we collected free-

text written responses to three questions about help-seeking behaviours for IBD-related FI. This

qualitative data from a subset of 636 respondents (20%) was dictated (continuing until saturation),

professionally transcribed, and thematically analysed4.

Results: of the whole cohort (n=3264), 74% (n=2415) reported some degree of FI. Of these, only

38% (n=927) reported seeking help for it. In the subset data (n=636), help was described as

Satisfactory, Unsatisfactory, or Alternative (acupuncture, counselling, hypnotherapy). Reasons for

not seeking help included believing nothing could be done, not knowing who to ask, feeling too

embarrassed, ashamed or dirty, and lack of interest, sympathy or understanding from health care

professionals. Very few reported awareness of specialist continence services or standard (in non-

IBD FI) treatments. IBD specialist nurses, where accessed, gave reassurance but apparently did not

employ techniques known to work for FI in other patient groups. Desired services to manage faecal

incontinence focussed around raising awareness amongst public, employers, and policymakers

thereby enhancing access to existing services and facilitating self-management of bowel activity.

Few seemed to think that it might be feasible to resolve FI.

Conclusions: Many people with IBD-related FI are not aware of the services or treatments that are

available to help them manage this distressing problem, or avoid seeking help often due to

embarrassment and taboo. Clinical staff could communicate their awareness for the potential for FI

to occur by proactively asking about symptoms during clinic appointments, or by using an

assessment tool to provide an opportunity for symptoms to be disclosed and described.

References:

1. Casati J, Toner BB, De Rooy EC et al (2000) Concerns of Patients with Inflammatory Bowel Disease: A Review of

Emerging Themes. Digestive Diseases and Sciences 45;1:26-31.

2. Leigh RJ, & Turnberg LA (1982) Faecal incontinence: the unvoiced symptom. The Lancet 319; 8258:1349-1351.

3. Norton C, Dibley L, Bassett P. Faecal incontinence in inflammatory bowel disease (IBD): associations and effect on

quality of life. Journal of Crohn’s & Colitis 2012. Online 8.12.2012. DOI:10.1016/j.crohns.2012.11.004

4. Fereday J & Muir-Cochrane E (2006) Demonstrating rigor using thematic analysis: a hybrid approach of inductive and

deductive coding and theme development. International Journal of Qualitative Methods

41

Kirstie Coxon

Do birth place decisions change over a woman’s childbearing career? In England, most women give birth in hospital obstetric units (OUs). First births usually occur in an OU, and women are thought more likely to opt for a different place of birth in subsequent pregnancies, especially if their first births are straightforward. However, this assumption is not based on evidence, because few studies explore the impact of birth on future birth place intentions.

This NIHR-funded research used a longitudinal, narrative design; 41 women with mixed parity and clinical risk profiles were recruited, using a maximum variation sampling strategy, and 113 interviews were conducted during pregnancy, birth and the early postnatal period. Longitudinal data analysis explored the influence of events during birth upon future birth place intentions.

Planned place of birth, willingness to consider different settings and the timing of birth place decisions all differed by parity. Most women who intended to give birth in hospital did so; following birth, they would usually do the same in future, even if their births were straightforward. Women who planned birth in non-hospital settings were less likely to achieve this, especially during first pregnancies, but usually wanted to achieve non-hospital birth in the future.

These findings raise questions about the effect of birth place decisions made during one pregnancy upon women's subsequent childbearing careers, and have implications for the sustainability of options other than obstetrician-led units. When balancing risks and benefits of OU birth in one pregnancy, it is important to consider the impact this experience might have on women’s future birth place decisions.

42

Nicola Mackintosh

The Hidden Nature Of ‘Diagnostic Rescue’ Work Policy discourse regarding ‘rescue of the acutely ill patient’ demarcates distinct stages to this process. These include monitoring, recognition of warning signs, interpretation and timely institution of appropriate clinical management once deterioration is identified. This categorisation presents too simplistic a picture of medical work and creates an illusion of transparency (Tsoukas, 1997). This doctoral study details how the majority of rescue work is distributed, collaborative and reflexive. Caring for acutely ill patients is underpinned by much hidden diagnostic work, i.e. the ‘intertwined practices of sense-making, assessment and action’ (Büscher, Goodwin, & Mesman, 2010 p.3). These diagnostic processes embody the nature and status of different types of rescue work and determine perceived notions of both the accuracy of interpretations and appropriateness of actions. This paper draws on findings from a 12 month ethnographic study of the management of complications in medicine in two UK NHS Trusts. Data will be presented from participant observations (>150 hours) and interviews (35) with health care assistants, nurses, doctors and managers.

Implications for practice

This paper responds to calls for patient safety research to explore the ‘embodied, spatial, and interactive fabric of care’ (Iedema 2009). It shifts patient safety thinking away from a deficit model towards what Mesman terms ‘exnovation’, or the process of making existing team work strengths explicit (2008). It aims to facilitate debate regarding the importance of collaborative, mundane, ‘mind-the gap’ work in maintaining safety.

43

Tracy Lindsay

Critical Reflections on Interpretative Phonological Analysis (IPA) Background

In the National Dementia Strategy (32009) there was a demand for earlier diagnosis of dementia and further development of memory clinic services. The available research and recommendations for the care of people with dementia has been based on the experiences and opinions of family carer and health care professionals. In the UK there is a dearth of research drawing on the lived experience of the person with dementia. My study is a phenomenological study which aims to explore the experiences of the person with dementia, after they receive a formal diagnosis. The study aims to utilise IPA to analysis the data collected.

Aim

To highlight the purpose of IPA, why I chose this approach and to explore my experience of IPA to date.

Critique

IPA was first developed in the mid 1990’s by Jonathan Smith and is well established within qualitative psychology. IPA is an appropriate approach to analysis when hoping to understand the lived experience, especially when the phenomenon under investigation is unknown. IPA is often seen as an easy option. Initially, when I was reading papers that utilised IPA, I became concerned that it was very descriptive and that it was a form of thematic analysis. However, I have come to recognise that IPA is committed to understanding the first persons perspective and when used effectively is interpretative in its focus. Phenomenological, idiographic and hermeneutics principles form the epistemological foundations of IPA. IPA focuses on what matters to the participants and focuses on the meaning of an experience.

Conclusion

IPA appears to be an innovative approach to analysis, which may be instrumental to providing insight in the world of the person with a diagnosis of dementia . IPA recognises the role of the researcher in the research process, bringing such insights to light.

44

Geraldine Lee

A pilot study to determine the feasibility of a pre-operative intervention in patients with diabetes undergoing cardiac surgery Authors: G. A Lee1, S. Wyatt2, D.Topliss3, K.Z.Walker4, R.Stoney5

Background: Coronary heart disease is common in Type 2 diabetes and often requires cardiac surgery. However poorer outcomes have been reported including increased rates of post-operative infection and prolonged hospital stay.

Aim: The aim of the study was to determine the feasibility and acceptability of a specialist consultation model (pre-operative medical and educational intervention) for type 2 diabetes in the cardiac surgery setting.

Methods: Twenty four patients were assigned usual care or to the intervention group. The intervention group were assessed by a diabetes clinical nurse consultant, dietitian, and endocrinologist during a pre-operative visit. Specific diabetes questionnaires were administered, education was delivered, and protocol-driven changes to the medical regimen were instituted. Length of stay, incidence of post-operative complications, and number of post-operative inpatient review endocrinology visits required were recorded.

Results: Twenty four patients with a pre-operative HbA1c greater than 6.5% (48 mmol/mol) were studied (17 males and 7 females). In the usual care group (n=15), HbA1c pre-operatively was 7.2% (55.2 mmol/mol) compared to 10.1% (86.9 mmol/mol) in the intervention group (n=9). Six weeks post-operatively HbA1c fell significantly in the intervention group by 1.9% (to 8.2% [66.1 mmol/mol]) compared to a reduction of 1.2% (to 7.0% [53 mmol/mol]) in the usual care group (p< 0.05). No significant differences were observed in length of stay in intensive care or in total hospital stay between the groups: length of ICU stay 54 hrs for intervention versus 47 hrs for usual care, total hospital stay (mean 8 days for both); or in rates of post-operative infection. Differences were seen between in the diabetes questionnaires: in the Problem Areas in Diabetes questionnaire and in the Diabetes Treatment Satisfaction Questionnaire (p = 0.048).

Conclusion: This small pilot feasibility study suggests there is potential benefit in the acute optimisation of diabetes treatment before elective cardiac surgery.

1. Dr G.A. Lee, PhD, BSc, PGDE, RGN, Lecturer, Florence Nightingale School of Nursing & Midwifery, Kings College London, UK

2. S. Wyatt, RN CDE, Diabetes Education Manager, Dept of Endocrinology & Diabetes, Alfred & Caulfield Hospital, Melbourne, Australia

3. D. Topliss, MD FRACP FACE Director, Dept of Endocrinology & Diabetes, Professor of Medicine (adjunct), Monash University, Alfred Hospital, Melbourne, Australia

4. K.Z Walker, PhD, MND Grad Dip HigherEd APD Associate Professor Dept of Nutrition and Dietetics, Monash University, Melbourne, Australia

5. R. Stoney, PhD, MND, Director Nutrition & Dietetics, Redland Hospital, Cleveland,

Queensland, Australia.

45

Julia Philippou

Don’t forget to get pregnant! The synchronism and asynchronism of family and career. Abstract (300 word limit): Recent research on careers have paid particular attention to the changing nature of labour markets and the effect on family-work integration. Particular attention has been paid to trends of women delaying having children or choosing not to have them at all and the dynamics that allow women to achieve career and life fulfilment. This paper examines the changing nature of nurses’ careers and identifies issues surrounding career-family integration. Data were collected from 33 semi-structured interviews with nurse employers and employees, as part of a larger scale study conducted in 5 Acute Trust across London. The effect of the traditional family cycle of marriage, childbirth, child rearing, and empty nest has been identified to have considerable implications on individual nurses’ careers. The study identifies a complex relationship of work-related dynamics and personal factors influencing nurses’ careers and the meaning they give to their career in the context of competing demands of family, individual life and work integration. Organisational support was fundamental to finding balance between career and personal life however what constitutes an appropriate balance differs from person to person. A deep sense of motherhood was evident in participants’ accounts with children being the number one priority, but, career was of high importance with participants searching for stimulation, achievement and enrichment of their work. The study contributes to recent career theory and raises the importance of work-life integration particularly in a female dominated profession such as nursing. Findings raise important issues for the management of nurses’ careers. The skills involved in navigating careers and maintaining work-life integration in the light of the changing landscape of careers are now necessary for all individuals regardless of the sector in which they are employed.

46

Lynn Sayer

Pennies from Heaven: Using Opportunistic Funding for Workforce Development and Evaluation Research As a result of the Health Visitor Implementation Plan (DH 2011) 600 new health visitor students are expected in London between 2011 and 2015. Each will be allocated a Practice Teacher (PT) who will also manage a caseload of up to 1,000 families. In 2012 unanticipated and additional funding was given to each London HEI to facilitate support for student placements. We offered partnership with service colleagues to initiate two centres of clinical learning (COLs) with one PT in each who will have a lightened caseload for up to two years in order to focus on supporting students and developing on-site programmes of clinical education. The COL will also influence practice at other smaller satellite clinics or 'spokes'; academics from KCL will both support the educational initiative and evaluate the project.

Each stage of project development will be accompanied by research and evaluative activity.

Stage1, engagement with different stakeholders, including

(i) A literature review to establish current knowledge of partnerships between HEIs and Service providers to deliver clinical education within practice; and

(ii) Interviews exploring stakeholder perspectives at Strategic Health Authority, service management and service delivery levels. Data from the interviews will help to identify project goals and establish measurable benchmarks of attainment.

Stage 2, project initiation will include data extraction from key documents describing the dynamics and processes supporting establishment of the COL and spoke system including selection of the PTs and identification of their clinical bases. Interviews with the stakeholders will explore perceptions of the changes taking place and the extent to which interim measures of success (as identified in stage 1) have been attained.

Stage 3, operational stage, observation and interviews will provide a rich description of the COL and spokes as they develop over time and to assess their achievement against the final benchmarks of attainment.

Ref: Department of Health (DH) Health Visitor Implementation Plan. A Call to Action. Department of Health

47

Katerina Iliopoulou

Impact of an educational multimodal program on rate of ventilator-associated pneumonia in an intensive care unit in one Greek Hospital

The proposed study intents to determine whether a multimodal educational program could

decrease the rate of ventilator-associated pneumonia (VAP) in a hospital located in Greece.

Hospitalized, critically ill patients receiving mechanical ventilation have a significant risk of

developing ventilator-associated pneumonia. A review of the literature which includes evidence

from empirical studies indicates that the implementation of an integrated multimodal educational

program can demonstrate improved and sustained compliance with preventive measures towards

VAP resulting in its reduction.

Using a pre-/post-intervention study approximately 1200 patients within a 23-bed general ICU at a

University Hospital will be observed to establish the rate of VAP throughout the study period.

Data will be collected for nine months prior to, nine months during and nine months following the

implementation of a volunteer multimodal educational program emphasizing correct practices for

the prevention of VAP. The educational program will target to all (n=90) health care workers

(HCWs) of the participating ICU and it will consist of education and feedback components.

Education will include a tutorial session; compliance assessment with six targeted preventive

measures based on evidence based guidelines; a knowledge test on VAP preventive measures and

finally reminders to reinforce the information. Feedback on both VAP rates and performance

assessments will also be provided to reinforce changes. Data analysis will identify changes in VAP

rate by comparing VAP rates and changes in compliance with six measures for VAP prevention

between pre and post intervention periods. Demographic data of patients will also be compared pre

and post intervention period.

The proposed study is significant for Greece which is lacking formal education and formal infection control programs for the prevention of VAP. Findings can be used to promote optimal infection control programs for the prevention of VAP and to inform education by increasing the knowledge base and awareness of the problem of VAP amongst HCWs within critical care settings.

48

Henrietta Mulnier

The effect of a self-management programme on glycaemic control and weight in people with established diabetes in Lambeth and Southwark. Authors: Dr Henrietta Mulnier1, Ms Wenda Aitchison2, Ms Elizabeth Camfield2, Mrs Jennifer Sharp2, Prof Angus Forbes1, Ms Anna Reid2.

Aims

The Co-Creating Health (CCH) project has been running nationally for five years. A component of that project was a self-management programme (SMP) developed locally for people with diabetes. This abstract provides evidence for the impact on glycaemic control and weight in the London Boroughs of Lambeth and Southwark.

Method

Data were collected retrospectively using the date the individual joined the programme as the index date. A glycated haemoglobin (HbA1c) within 1 year before the index date was accepted as the person’s baseline. A reading more than eight weeks after, but within one year from starting; accepted as a post-programme reading.

Results

There were 87 people with an HbA1c before and after the programme. Of those 42 were men (48%), the average age was 63-years (range41-83, SD10.4 years), and average diabetes duration was 9.9 years (range 1-30 years, SD 7.0 years). The mean pre-programme HbA1c was 7.7% (SD 1.73%) and post-programme 7.4% (SD 1.7%), with a statistically significant fall of 0.27% (95% CI 0.007-0.54) p0.044. Mean pre-programme weight was 87.3Kg (SD 19.8) with a drop to post-programme of 0.72Kg, which was not significant. In a sub-set of 40 patients with a baseline HbA1c of >7.5% (range 8.0-16% [SD1.63]) there was a statistically significant drop in HbA1c of 0.8% (95% CI 0.24-1.36) p0.006, with a none significant drop in weight of 0.71Kg (SD 4.2Kg).

Conclusion

The overall data show a modest improvement in glycaemic control without weight gain, which is usually difficult to achieve especially in individuals with established diabetes (1). The data from the subset show a clinically and statistically significant improvement in HbA1c, the degree of which is as good as that seen in some of the newer antidiabetic agents (2). The results show that self-management can support individuals to improve their diabetes control significantly.

References:

1. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352(9131):837-53.

2. Aschner P, Kipnes MS, Lunceford JK, Sanchez M, Mickel C, Williams-Herman DE; Sitagliptin Study 021 Group. Effect of the dipeptidyl peptidase-4 inhibitor sitagliptin as monotherapy on glycemic control in patients with type 2 diabetes. Diabetes Care 2006; 29(12):2632-7

49

Lesley Bridges

The Impact of Postgraduate Advanced Practice Programmes; An Evaluation Study

Introduction and Purpose: Over the past decade we have witnessed a proliferation of advanced practice roles within healthcare practice, in response to the necessity to re-organise services to meet demographic changes; and utilise precious resources more effectively to meet challenging patient needs. There is evidence, however to suggest, that service providers perceive that advanced practitioners are ill prepared for practice and lack specific competencies needed by current healthcare . This is compounded by the lack of evidence relating to educational effectiveness. This presentation aims to present an overview of this evidence to date and the details of an ongoing project to evaluate the impact of postgraduate advanced practice programmes to students and NHS Trusts.

Methods: The research being undertaken uses a case study approach as a disciplined mode of enquiry to explore student and Trust Partners experiences of the translation of student learning from postgraduate advanced practice programmes to practice. Three cases were selected for this study one in London, one in the Midlands and one in the North to determine similarities and differences where the case is the educational programme. 28 students from the three cases have been interviewed, and managers/ qualified advanced practitioners from six NHS Trusts using focus groups to collect data.

Conclusions and recommendations: In conclusion, it is imperative that best evidence is utilised to underpin and support the continuation of advanced practice educational programmes. With the introduction of the Advanced Practice Standards (DoH 2010a) and the directive that that postgraduate programmes should underpin the education of advanced practitioners there is a need to develop consistency amongst higher education institutions who deliver these programmes. Data analysis to date of one of the cases demonstrates a limited understanding of the advanced practice role. Student perceptions of the effectiveness of the role include improved communication, increased autonomy, increased confidence and improved patient care.

50

Tanya Graham

How are topical opioids used to manage painful cutaneous lesions in palliative care? A critical review

Background:

Cutaneous lesions can be painful, difficult to heal, and negatively impact quality of life. There is growing consensus that topical opioids relieve inflammatory pain without the side effects associated with systemic analgesics. Previous reviews have focussed on the effectiveness of topical opioids and a brief investigation of wound aetiology but did not assess the impact of titration or patients’ views. A critical review of topical opioid use for the management of painful cutaneous lesions is presented.

Methods:

A systematic search was conducted across seven databases (EMBASE; MEDLINE; CINAHL; Cochrane Library; Biomed Central; NHS evidence; British Nursing Index) including all types of study design except reviews. Studies in English, German, French and Italian were included as well as studies which found topical opioids to be both effective and non-effective. A narrative analysis was conducted.

Results:

The search generated 77 papers. Following assessment of titles and abstracts 27 papers were included in the review reporting upon a total of 170 patients. Most commonly analgesic relief was achieved for patients with pressure and malignant wounds indicating the importance of inflammation. Dose titration to achieve pain control occurred but did not follow any systematic method. Doses also varied widely with little explanation as to why. Systemic uptake of topical opioids was reported at levels considered safe. Patients’ views were under represented.

Conclusions:

Standard approaches to assess inflammation and infection are needed to assist clinical decision-making. A systematic approach to establishing the effectiveness and dose-response relationship of topical opioids is required to inform clinical guidelines. Study designs, such as an n-of-1 trial, are needed to evaluate topical opioids use in patients with multiple variables and heterogeneous presentation of inflamed lesions. This research could be better aligned to patient need by incorporating experienced-based co-design methodologies.

51

Vania Gerova

Emergency Caesarian section of low and high risk women: the impact of maternity staffing, NHS England 2010/11

Aim: This part of the study aims to explore the effect of maternity staffing on emergency CS rates for low and high risk, nulliparous, singleton pregnancy women, aged 15-44 by using routinely available data for England in 2010/11.

Background: Caesarean section (CS) deliveries are associated with higher costs and maternal complications ...but CS procedure could be life saving and the optimum rate is unknown (WHO, 2009). There is evidence of great variations in CS rates between trusts/hospitals in England after adjusting for maternal demographic and clinical factors (Bragg et al, 2010; RCOG, 2013) and these seem to be due to variations in emergency CS and management practices. Joyce et al (2002) showed a positive association between CS rates and junior but not consultant medical staff and no association between midwifery staffing levels and CS rates.

Study questions: If emergency CS is a main contributor to the overall variations in CS between trusts, it is of interest to understand what drives emergency CS variations. Is there an association between emergency CS and maternal age, ethnicity, deprivation, gestational age and birth weight after controlling for maternal clinical risk factors? Could maternity staffing levels and certain trust characteristics explain any of the variations in emergency CS between trusts?

Methods and Data: The data are from 2010/11 Hospital Episode Statistics (HES) matched to September 2010 NHS IC medical and non-medical staff data at trust level. Outcomes - emergency CS for low and high risk nulliparous women with singleton pregnancy, aged 15-44. ’Risk’ is defined in NICE Clininical Guideline 55 on Intrapartum Care, 2007. A multilevel binary logistic regression analysis is applied allowing to model hierarchical data, i.e. patients (Level 1) within trusts (Level 2). Explanatory variables at Level 1 (maternal age, ethnicity, IMD, gestational age, birth weight), Level 2 (consultants/registrars/midwives FTE per delivery; London/Foundation/Teaching Trust; Trust configuration).

Preliminary results: There were 657,480 women in 143 trusts, of which 14.7% had emergency CS. 161,248 women were low risk and 114,690 high risk (all nulliparous, singleton pregnancy, aged 15-44 years). 14% in the low risk and 28.2% in the high risk group experienced emergency CS. There was very little variation between trusts in the probability of emergency CS for low and high risk women; strong and statistically significant associations between maternal characteristics and emergency CS, inverse but not significant relationships between midwives FTE and registrars FTE per delivery and emergency CS (positive and not significant for consultants FTE/delivery); none of the other trusts characteristics were significant at 5% level.

52

Uta Grosse

The Experience of Nurses Working in a Tuberculosis Hospital in South Africa: An Ethnographic Study In 2011 alone, 8.7 million people developed active Tuberculosis (TB) worldwide. South Africa has one of the highest rates of acute TB infection with an incidence rate of 993 per 100.000 population and the disease is a major cause of morbidity and mortality in that country. Nurses play a key role in the management and care of TB, but there is little research exploring the lives and work of TB nurses in such contexts. This doctoral study explores experiences of nurses working in a TB hospital in South Africa. It examines their motivations, career histories, and personal relationships with co-workers, family and community; their experience of working in sensitive and drug-resistant TB environments and their attitudes towards risk of infection; and their attitudes, beliefs and behaviours with regard to the needs and care of patients. The study adopts a qualitative approach, and employs ethnography as its study design and methodological framework. It uses multiple methods of data collection, observation in the hospital, semi-structured interviews with 30 nurses, and an adaptation of the visual method PhotoVoice. Fieldwork took place over a period of 6 months in a TB hospital in Western Cape, South Africa. Field notes, interview transcripts and visual material were subjected to thematic analysis with assistance of NVivo software. The thesis considers the extent to which the TB hospital can be conceived of as a ‘total institution’ in accordance with Goffman’s (1961) classic typology. It concludes that the hospital has some of the key characteristics, such as isolation from the outside world, high levels of ‘security’ and surveillance, ‘batch living’ and uniform treatment of all patients. The rationalisation of everyday life, a central element of total institutions, was also reflected in the work hierarchies, the task orientation of nursing duties and a monotonous daily routine for patients and staff. Within this the nurses have a dual role, they are both enforcers of the rules of this total institution and subjects of them. However, the latter meets with some opposition and subversion. This was most apparent in staff attitudes to infection risk. In a situation where some patients had moderate or extreme drug resistance the hospital had strict infection control protocols, which were exhibited on walls and also in the photos taken by the nurses. But nurses themselves often deviated from these with risky behaviours, in ways that suggest attempts to maintain personal autonomy in a highly regulated environment, and which drew on alternative authorities of fate and faith. The thesis demonstrates the different ways in which nurses navigated the tension between role autonomy and infection control in different ways in different parts of the hospital. When considered from the perspective of a key workforce, TB care presents complex social as well as organisational, political and epidemiological challenges.

53

Judith Parson

Preventing type 2 diabetes after gestational diabetes

Gestational diabetes mellitus (GDM) affects around 5% of pregnancies. Although GDM usually resolves after birth, women with the condition are over seven times more likely to develop type 2 diabetes in the future than other women. They are also at high risk of having another episode of GDM, and offspring of women with diabetes in pregnancy are more likely to develop obesity and type 2 diabetes. Type 2 diabetes is associated with long-term complications, but can be delayed or prevented in high-risk populations through lifestyle interventions promoting healthy eating, physical activity or weight loss. Qualitative research shows that postpartum women may face different barriers to engaging in lifestyle change to the general population, and therefore require a tailored intervention to support diabetes prevention. However, there is little research on prevention of type 2 diabetes with women with GDM, and no UK research. This study aims to develop and test the feasibility and preliminary efficacy of a lifestyle intervention for women with recent GDM. The intervention will consist of information as well as support with behaviour change, and is designed to be delivered within the current healthcare system. The study has three phases: (1) intervention development through conducting a meta-synthesis of women’s experiences of GDM, systematic reviews of interventions and focus groups with women with GDM; (2) exploring acceptability of the intervention by running a small test version; and (3) a feasibility randomised controlled trial where the intervention will be tested through randomising 40 women with GDM to the intervention or usual care. The last phase will also include a qualitative study of participants’ experiences of the intervention as well as a process evaluation. If successful, it is hoped this study will inform a future large-scale trial of a complex intervention to prevent type 2 diabetes in women with GDM.